FIBROID UTERUS- A DEEP INSIGHT

PRESENTED BY: VISHNU.R.NAIR,4TH YEAR PHARM.D,NATIONAL COLLEGE OF PHARMACY,KERALA UNIVERSITY OF HEALTH SCIENCES(KUHS), KERALA STATE

INDEX/ CONTENTS OF THIS PPT : GENERAL ACKNOWLEDGEMENTGENERAL INTRODUCTION EPIDEMIOLOGICAL STATISTICS TYPES OF FIBROIDS ETIOLOGY/ CAUSES OF FIBROIDS PATHOPHYSIOLOGY CLINICAL MANIFESTATIONS RISK FACTORS FOR FIBROIDS COMPLICATIONS OF FIBROIDS DIAGNOSTIC PRINCIPLES FOR FIBROIDS MANAGEMENT STRATEGIES FOR FIBROIDS BIBLIOGRAPHY/ REFERENCE

GENERAL ACKNOWLEDGEMENT :HELLO READERS………………….ITS MY 21ST PPT……………………………AS FAR AS MAKING THIS PPT IS CONCERNED, I WISH TO THANK THE ALMIGHTY, MY EVER-LOVING PARENTS, DEAR TEACHERS OF 4TH YEAR, MY FRIENDS, PHARM.D GROUP MEMBERS AND EVERYONE, NEAR AND DEAR, FOR UR SUPPORT, CARE & GUIDANCE IN MY INITIATIVES N WORKS……..WITH A NOTE OF THANKS, I SURELY HOPE THAT THIS PPT WILL PROVE WORTHY FOR ANYONE WHO GO THROUGH ITDO SEND ME UR REVIEWS N COMMENTS!!!@RXVICHU-ALWZ4UH!

GENERAL INTRODUCTION :1. UTERINE FIBROIDS are defined as “NON-CANCEROUS GROWTHS of

UTERUS, that usually appear during CHILDBEARING YEARS”2. Also known as “ UTERINE LEIOMYOMAS”/ simply “MYOMAS”3. Not associated (in most cases) , with UTERINE CANCER4. FIBROID SIZE varies from SEEDLINGS(undetectable by human eye), to

BULKY MASSES, that can DISTORT/ ENLARGE the UTERUS5. Fibroid may be SINGLE in OCCURRENCE/ MULTIPLE in number6. Many women have UTERINE FIBROIDS at sometime in their lives7. Most women do not know that they have fibroids, since they often are

ASYMPTOMATIC……………………………

EPIDEMIOLOGICAL STATISTICS :1. According to NATIONAL INSTITUTE OF HEALTH, about 70-80% of

women experience FIBROIDS by age 502. About 77% specimens of HYSTERECTOMY(Conducted in US), were

found to have FIBROIDS, in VARIABLE NUMBERS, SIZES & SITES3. According to SONOGRAPHIC SURVEY in 35-49 years aged AFRO-

AMERICAN WOMEN 60% FIBROIDS were reported in them4. WHITE WOMEN have LOWER PREVALENCE : 40% at age 35, and

almost 70% by age 50……………………….

TYPES OF FIBROIDS :FIBROIDS ARE CLASSIFIED AS:

1. INTRAMURAL FIBROIDS:- MOST COMMON type of fibroid- Appears within UTERUS LINING(ENDOMETRIUM)- May grow larger & cause WOMB SWELLING

2. SUB-SEROSAL FIBROIDS:- Form on OUTSIDE of UTERUS(SEROSA)- May grow large enough to make WOMB appear BIGGER ON ONE SIDE

3. PEDUNCULATED FIBROIDS:- When SUBSEROSAL TUMORS develop a STEM(SLENDER BASE, that

supports the TUMOR) PEDUNCULATED TUMORS are formed

4. SUBMUCOSAL FIBROIDS :- Develop in INNER LINING (MYOMETRIUM) of UTERUS- Not as common as other types- Cause HEAVY MENSTRUAL BLEEDING & TROUBLE in

CONCEIVING…………………….

ETIOLOGY/ CAUSES OF FIBROIDS :CAUSES OF FIBROIDS INCLUDE:

1. GENETIC CAUSES:- FIBROIDS are usually MONOCLONAL- 40% include CHROMOSOMAL ABNORMALITIES- 60% include UNDETECTED MUTATIONS- CHROMOSOMAL ABNORMALITIES include:a. TRANSLOCATIONS between CHROMOSOMES 12 & 14b. DELETION of CHROMOSOME 7c. TRISOMY of CHROMOSOME 12 (in LARGE TUMORS)

2. HORMONES:- ESTROGEN & PROGESTERONE (Hormones, that stimulate

DEVELOPMENT of UTERINE LINING, during each MENSTRUAL CYCLE , in preparation for PREGNANCY) PROMOTES FIBROID GROWTH- Fibroids contain more ESTROGEN & PROGESTERONE RECEPTORS than

NORMAL UTERINE MUSCLE CELLS do- ESTROGEN induces INCREASED EXPRESSION of PROGESTERONE

RECEPTORS Promotes ONCOGENIC EFFECTS of PROGESTERONE- This explains why:a. Fibroids tend to SHRINK after MENOPAUSEb. Fibroids tend to occur during HRT(ERT)

3. GROWTH FACTORS:- GROWTH FACTORS PROTEIN POLYPEPTIDES , produced LOCALLY by

SMOOTH MUSCLE CELLS & FIBROBLASTS- GROWTH FACTORS increase EXTRACELLULAR MATRIX promote

FIBROID GROWTH- GROWTH FACTORS include:a. TUMOR-GROWTH FACTOR(BETA)b. BASIC FIBROBLAST GROWTH FACTORc. EPIDERMAL GROWTH FACTOR(EGF)d. PLATELET DERIVED GROWTH FACTOR (PDGF)e. VASCULAR ENDOTHELIAL FACTOR (VEF)f. INSULIN- LIKE GROWTH FACTOR

4. MISCELLANEOUS CAUSES:INCLUDE:a. OBESITYb. ERTc. ENDOMETRIOSISd. ENDOMETRIAL CANCERe. OVULATORY INFERTILITYf. EARLY MENARCHEg. PREGNANCY………………………………………………….

PATHOPHYSIOLOGY OF FIBROIDS :- There are 2 types of FACTORS, that cause FIBROID UTERUS:

1. PRE-DISPOSING FACTORS:INCLUDE:a. Age g. Use of ORAL

CONTRACEPTIVESb. Gender h. High fat dietc. Race i. Obesityd. Lifestyle j. Family historye. Early menarche k. Anxietyf. Nulliparity

2. PRECIPITATING FACTORS:INCLUDE:a. HORMONE REPLACEMENT THERAPY (HRT)b. LUTEAL INSUFFICIENCYc. ANOVULATION- Both PRE-DISPOSING & PRECIPITATING FACTORS Cause ESTROGEN

DOMINANCE If ESTROGEN DOMINANCE is not treated PROLIFERATION of CELLS in UTERUS occurs OVERGROWTH of ENDOMETRIAL LINING occurs UTERINE FIBROID develops FIBROIDS interferes with VASCULAR SUPPLY Causes DEGENERATION in INTERIOR PART of FIBROID causes HYPERMENORRHOEA, and OTHER SYMPTOMS………………………

- ESTROGEN DOMINANCE is associated with:a. SWELLING OF BREASTSb. DEPRESSIONc. LOSS OF SEXUAL DRIVEd. DYSMENORRHOEA………………………………

CLINICAL MANIFESTATIONS :1. HEAVY MENSTRUAL BLEEDING2. MENSTRUAL PERIODS, LASTING MORE THAN 1 WEEK3. PELVIC PRESSURE/ PAIN4. DIFFICULTY IN EMPTYING THE BLADDER 5. CONSTIPATION6. BACKACHE7. LEG PAINS8. ACUTE ABDOMINAL PAIN9. FREQUENT URINATION

10. DYSPAREUNIA11. ANOREXIA12. SWELLING/ ENLARGEMENT OF ABDOMEN…………………………..

RISK FACTORS FOR FIBROIDS :INCLUDE:

1. AGE:- Incidence increases with AGE, till ONSET of MENOPAUSE

2. ENDOGENOUS HORMONAL FACTORS:INCLUDE:a. EARLY MENARCHEb. LATE MENOPAUSEc. HYPER-ESTROGENIC STATESd. INCREASED RESPONSIVENESS & EXPRESSION OF PROGESTERONE

RECEPTORS ‘A’ & ‘B’

3. FAMILY HISTORY :- FIRST DEGREE RELATIVES have 3.5 TIMES more risk of DEVELOPING

FIBROIDS

4. ETHNICITY :- BLACK WOMEN develop FIBROIDS 2.9 TIMES more than WHITE WOMEN

5. BODY WEIGHT:- Risk of FIBROIDS increases by 21% , with each 10 KG increase in BODY WEIGHT

6. DIET :- Diet , rich in RED MEAT, HAM, BEEF Increases FIBROID RISK

7. EXERCISE:- Women doing REGULAR EXERCISE (at least 7 hrs./ week) have LOW RISK , than those who DON’T EXERCISE

8. ESTROGEN REPLACEMENT THERAPY:- Increased INCIDENCE observed when PROGESTERONE is added

9. PREGNANCY:- PREGNANCY increases production of ESTROGEN & PROGESTERONE

Encourages RAPID DEVELOPMENT of FIBROIDS

10. TISSUE INJURY:- Increases LOCAL PRODUCTION of TISSUE GROWTH FACTORS…………………………

COMPLICATIONS OF FIBROIDS :INCLUDE:1. ANEMIA (DUE TO HEAVY BLOOD LOSS)2. INFERTILITY3. PLACENTAL ABRUPTION4. FETAL GROWTH RESTRICTION5. PRE-TERM DELIVERY6. CHF………………………………….

DIAGNOSTIC PRINCIPLES FOR FIBROIDS

INCLUDE:1. ULTRASOUND:- ULTRASOUND uses SOUND WAVES obtains PICTURE of UTERUS

confirms diagnosis , and also helps to MEASURE FIBROIDS- DOCTOR/ TECHNICIAN Moves the ULTRASOUND DEVICE

(TRANSDUCER) over ABDOMEN (TRANS-ABDOMINAL) / places it inside VAGINA (TRANS-VAGINAL) , to get images of UTERUS

2. BLOOD TESTS:- If ABNORMAL MENSTRUATION is observed doctor may order other tests to investigate POTENTIAL CAUSES

- TESTS include:a. CBC (COMPLETE BLOOD COUNT) : To see if ANEMIA has occurred ,

due to CHRONIC BLOOD LOSSb. OTHER TESTS : TO RULE OUT OTHER BLEEDING DISORDERS/

THYROID PROBLEMS

3. MRI-SCAN :- Used for the following purposes:c. To show SIZE & LOCATION of FIBROIDSd. To identify DIFFERENT TUMOR TYPESe. To determine APPROPRIATE TREATMENT OPTIONS

4. HYSTEROSONOGRAPHY:- Also known as “SALINE INFUSION SONOGRAM”- Here STERILE SALINE is used EXPANDS UTERINE CAVITY Makes

easier to get images of SUBMUCOSAL FIBROIDS & ENDOMETRIUM

5. HYSTEROSALPINGOGRAPHY:- Here DYE is used HIGHLIGHTS UTERINE CAVITY & FALLOPIAN

TUBES on X-RAY IMAGES- Helps in:a. Revealing fibroidsb. To determine if FALLOPIAN TUBES are OPEN

6. HYSTEROSCOPY:- In this procedure doctor inserts a HYSTEROSCOPE (Small, lighted TELESCOPE) through CERVIX into UTERUS then SALINE is injected into UTERUS expands UTERINE CAVITY Allows doctor to examine walls of UTERUS & OPENINGS of FALLOPIAN TUBES……………………………..

MANAGEMENT STRATEGIES FOR FIBROIDS :INCLUDES:A. GOALS OF THERAPYB. PHARMACOTHERAPYC. NON-PHARMACOTHERAPY

A. GOALS OF THERAPY :1. TO RELIEVE PAIN & DISCOMFORT2. TO AVOID PROGRESSION INTO COMPLICATIONS3. TO ASSESS NEED OF THERAPY & ITS PROPER PLANNING4. TO IMPROVE HRQOL (HEALTH-RELATED QUALITY OF LIFE)5. TO ENSURE PATIENT CONVALESCENCE AS MUCH AS

POSSIBLE…………………….

B. PHARMACOTHERAPY :1. GNRH (GONADOTROPIN-RELEASING HORMONE)

AGONISTS:- TEMPORARY TREATMENT for PRE-MENOPAUSAL WOMEN, with HEAVY

MENORRHAGIA- Actions include:a. DRUG BLOCKS PRODUCTION of ESTROGEN & PROGESTERONE Puts

patient in a TEMPORARY MENOPAUSAL STATE MENSTRUATION STOPS FIBROIDS SHRINK ANEMIA IMPROVES

b. DRUG REDUCES UTERINE VOLUME by 35%c. DRUG REDUCES FIBROID VOLUME by 30%d. DRUG REDUCES BLEEDING

- SYMPTOMS RETURN , when MEDICATION IS STOPPED- Usually given for 3-6 MONTHS- DRUGS used include:

I. TRIPTORELIN (TRELSTAR):- MOA : DRUG REDUCES ‘FSH’ LEVELS SUPPRESSES

STEROIDOGENESIS REDUCES ESTROGEN levels - ADRs:• HOT FLUSHES (82%)• BONE PAIN (17%)• IMPOTENCE (10%)- INTERACTION : DRUG + AMIODARONE Increases TOXICITY OF LATTER High risk of TDP(TORSADES DE POINTES)

- DOSE : 3.75 mg DEPOT (i.m) MONTHLY……………

II. LEUPROLIDE ACETATE(LUPRON) :- MOA : DRUG INHIBITS GONADOTROPIN SECRETION SUPPRESSES

OVARIAN STEROIDOGENESIS REDUCES FSH LEVELS- AGONIST ANALOGUE OF LUTEINIZING HORMONE-RELEASING

HORMONE(LHRH)- ADRs:• HOT FLUSHES (57%)• ISCHEMIA (19%)• FATIGUE (18%)- INTERACTION : DRUG + AMIODARONE increased risk of TDP- DOSE : 3.75 mg DEPOT (i.m) MONTHLY……………………………….

III. GOSERELIN(ZOLADEX):- LHRH ANALOGUE- Same MOA as that of LEUPROLIDE- ADRs:• FLUSHING (46-96%)• VAGINITIS (5-75%)• BREAST ATROPHY (33%)• DEPRESSION IN WOMEN (54%)• REDUCED LIBIDO (47-61%)- INTERACTION : DRUG + AMIODARONE Increased risk of TDP- DOSE : 3.6 mg DEPOT (s.c) MONTHLY………………………………

4. NAFARELIN (SYNAREL):- SYNTHETIC DECAPEPTIDE- MOA : DRUG DESENSITIZES RESPONSE to ENDOGENOUS GnRH

REDUCES FSH SECRETION REDUCES OVARIAN PRODUCTION- ADRs:• ACNE (10%)• BREAST ENLARGEMENT (8%)• VAGINAL BLEEDING (8%)- DOSE : 200 mg , taken TWICE DAILY, INTRANASALLY ( ONE SPRAY into 1 NOSTRIL in MORNING, & 1 SPRAY into OTHER NOSTRIL at EVENING)

2. PROGESTIN-RELEASING INTRAUTERINE DEVICE:- REASONABLE TREATMENT for selected women of CHILD-BEARING

AGE , with FIBROID ASSOCIATED MENORRHAGIA, and interested to have CONCEPTION- Reduces HEAVY BLEEDING caused by FIBROIDS- Provides only SYMPTOMATIC RELIEF- Doesn’t SHRINK FIBROIDS/ make them DISAPPEAR- PREVENTS PREGNANCY- 85% of such women returned to their normal bleeding in 3 months- 40% developed REVERSIBLE AMENORRHEA at the end of 1.5-2 YEARS- Example : MIRENA-LEVONORGESTREL RELEASING

IUCD……………………………….

3. TRANSEXAMIC ACID (LYSTEDA):- NON-HORMONAL MEDICATION- EASES HEAVY MENSTRUAL PERIODS- Taken only on HEAVY BLEEDING DAYS- DOSE : 10mg/kg i.v (over 30 mins)……………………….

4. ORAL CONTRACEPTIVES/ PROGESTINS:- CONTROL MENSTRUAL BLEEDING- Don’t reduce fibroid size

5. NSAIDS:- RELIEVE PAIN associated with FIBROIDS- Don’t reduce BLEEDING caused by FIBROIDS

6. VITAMIN & IRON SUPPLEMENTS:- Used to control HEAVY MENORRHAGIA & ANEMIA…………………………………..

B. NON-PHARMACOTHERAPY : INCLUDES:1. NON-INVASIVE PROCEDURES2. MINIMALLY INVASIVE PROCEDURES3. TRADITIONAL SURGICAL PROCEDURES4. HOME REMEDIES FOR FIBROID UTERUS5. PATIENT COUNSELLING TIPS(DO’S FOR FIBROIDS)6. PATIENT COUNSELLING TIPS(DON’T’S FOR FIBROIDS)

1. NON – INVASIVE PROCEDURES :INCLUDES:I. FOCUSED ULTRASOUND SURGERY (FUS):- Helps in UTERUS PREPARATION- Requires NO INCISION- Done on OUT-PATIENT BASIS- Performed in presence of MRI-SCANNER, that is equipped with a HIGH-ENERGY

ULTRASOUND TRANSDUCER- IMAGE PROVIDED by TRANSDUCER Provides PRECISE LOCATION of

UTERINE FIBROIDS When LOCATION of the FIBROID is TARGETED ULTRASOUND TRANSDUCER FOCUSSES SOUND WAVES(SONICATIONS) into FIBROID HEATS & DESTROYS small areas of FIBROID TISSUE…………..

2. MINIMALLY INVASIVE PROCEDURES:

INCLUDE:I. UTERINE ARTERY EMBOLIZATION:- In this process SMALL PARTICLES (EMBOLIC AGENTS) INJECTED into

ARTERIES supplying the UTERUS CUTS OFF BLOOD SUPPLY to FIBROIDS Cause them to SHRINK & DIE- Complications may occur if the BLOOD SUPPLY to the OVARIES/ other

ORGANS is COMPROMISED……………………..

II. MYOLYSIS:- LAPAROSCOPIC PROCEDURE

- Here RADIOFREQUENCY ENERGY, ELECTRIC CURRENT / LASER is used DESTROYS FIBROIDS SHRINKS BLOOD VESSELS that feed them

- CRYOMYOLYSIS : Involves FREEZING of FIBROIDS

III. LAPAROSCOPIC/ ROBOTIC MYOMECTOMY:- During MYOMECTOMY SURGEON removes FIBROIDS, keeping UTERUS in its

place- LAPAROSCOPIC method is used if FIBROIDS are FEW & SMALL in NUMBER- Here SLENDER INSTRUMENTS are INSERTED through SMALL INCISIONS in

the ABDOMEN FIBROIDS are broken into SMALLER PIECES (A process, known as MORCELLATION)- ROBOTIC MYOMECTOMY gives surgeon a MAGNIFIED, 3-D IMAGE OF UTERUS

Provides MORE PRECISION,DEXTERITY & FLEXIBILITY…………………….

IV. HYSTEROSCOPIC MYOMECTOMY:- Applicable for SUB-MUCOSAL FIBROIDS- Here SURGEON removes FIBROIDS, using INSTRUMENTS, inserted

through VAGINA & CERVIX into the UTERUS

V. ENDOMETRIAL ABLATION:- Here a SPECIALIZED INSTRUMENT is inserted into UTERUS Uses HEAT, MICROWAVE ENERGY, HOT WATER/ ELECTRIC CURRENT Destroys UTERINE LINING Ends MENSTRUATION/ REDUCES MENSTRUAL FLOW…………………………

3. TRADITIONAL SURGICAL PROCEDURES:

INCLUDES:I. ABDOMINAL MYOMECTOMY:- Applicable for MULTIPLE FIBROIDS, VERY LARGE/ DEEP FIBROIDS- OPEN ABDOMINAL SURGICAL PROCEDURE- DEMERIT : SCARRING after surgery can affect future FERTILITY

II. HYSTERECTOMY:- Only proven PERMANENT SOLUTION for UTERINE FIBROIDS- Ends ABILITY TO HAVE CHILDREN, since the procedure involves

REMOVAL OF UTERUS as such……….

4. HOME REMEDIES FOR FIBROID UTERUS :INCLUDE:I. CASTOR OIL PACK:- CASTOR OIL PACK Applied on ABDOMEN Stimulates LYMPHATIC & CIRCULATORY

SYSTEM Increases LYMPHOCYTES (Disease- fighting cells) Eliminates TOXINS from body

- CASTOR OIL Contains RICINOLEIC ACID has ANTI-INFLAMMATORY ACTION SHRINKS FIBROIDS Relives PAIN

- SATURATE a piece of WOOL FLANNEL in CASTOR OIL Place it on your ABDOMEN Cover it with a PLASTIC WRAP Place HEATING PAD/ HOT WATER BOTTLE on it cover it with an OLD TOWEL Leave it on for about 1 HOUR REMOVE IT REPEAT 3-4 times a week, (for 1 month), unless SYMPTOMS RESOLVE

- NEVER USE THIS REMEDY during MENSTRUATION/ if you are trying to CONCEIVE…………

II. CHASTEBERRY:- Also known as “VITEX AGNUS-CASTUS”- Found in SOUTHERN EUROPE & MEDITERRANEAN AREAS- Good HERBAL SOLUTION to maintain HORMONAL BALANCE, REDUCE

ESTROGEN LEVELS, & REDUCE INFLAMMATION- Take 25-30 drops of CHASTEBERRY TINCTURE TWICE/ FOUR TIMES DAILY- CHASTEBERRY may REDUCE EFFECTIVENESS of BIRTH CONTROL

PILLS…………………..

III. MILK THISTLE:- METABOLIZES & gets RID of EXCESS ESTROGEN- Take 15-20 drops of its TINCTURE (THRICE DAILY) for 3-4

months……………………

IV. DANDELION:- According to HERBALISTS POOR LIVER FUNCTION Causes POOR

ELIMINATION of EXCESS HORMONES results in FIBROIDS- DANDELION has 2 actions:a. Aids in LIVER DETOXIFICATIONb. Clears EXCESS ESTROGEN from the body- BOIL 3 tbsp. of DANDELION ROOT in 3.5 cup water let it SIMMER for

15 minutes turn off heat allow to steep for 15 minutes STRAIN it Drink this tea thrice daily for 3 months………

V. GREEN TEA:- According to STUDIES GREEN TEA contains a compound called

“EPIGALLOCATECHIN GALLATE(EGCG)” INHIBITS GROWTH of FIBROID CELLS Increases its DEATH RATE- EGCG Has ANTI-INFLAMMATORY, ANTI-PROLIFERATIVE & ANTI-OXIDANT

effects- According to RESEARCHERS Along with reducing FIBROID SIZE GREEN TEA

also reduces SEVERITY of FIBROID SYMPTOMS- Drink 2-3 cups of GREEN TEA daily for several months………………………

VI. MILK:- According to a study published in AMERICAN JOURNAL OF EPIDEMIOLOGY in 2009 RESEARCHERS at BOSTON UNIVERSITY SCHOOL OF MEDICINE found that BLACK WOMEN, who consumed 4/ more DAIRY SERVINGS a day, had 30% REDUCED RISK of UTERINE FIBROIDS, compared to those with <1 serving/day

- CALCIUM found in milk reduces CELL PROLIFERATION- Combine MILK with BLACKSTRAP MOLASSES(rich in IRON) Helps to

FIGHT ANEMIA , resulting from HEAVY BLEEDING due to FIBROIDS- Mix 1-2 tbsp. BLACKSTRAP MOLASSES in a cup of WARM MILK Drink it

OD/ BID, for few months……………………………..

VII. BURDOCK ROOT TEA:- Improves LIVER’S ABILITY to METABOLIZE ESTROGEN Reduces

FIBROIDS- BURDOCK ROOT Contains LIGNAN “ARCTIGENIN” Reduces FIBROID

SIZE Prevents NEW TUMOR GROWTH- Add 1 tsp. of DRIED BURDOCK ROOT to a cup of HOT WATER STEEP

for 10-15 minutes STRAIN it Drink it TID, for 3-4 months…………………………………….

VIII. APPLE CIDER VINEGAR:- APPLE CIDER VINEGAR REMOVES TOXINS & PROMOTES FAT LOSS helps to REDUCE FIBROID SYMPTOMS- Add 1 tsp of APPLE CIDER VINEGAR to a glass of water add NATURAL

SWEETENER to taste drink it daily on a regular basis ………..

IX. GARLIC:- NATURAL ANTI-OXIDANT & ANTI-INFLAMMATORY AGENT- Reduces GROWTH of TUMORS & UTERINE FIBROIDS- Eat 3-4 GARLIC CLOVES a day, along with a glass of milk………..

X. INDIAN GOOSEBERRY(AMLA):- AMLA POTENT ANTI-OXIDANT & IMMUNOMODULATOR REDUCES FIBROIDS & their SYMPTOMS- Mix 1 tsp of AMLA POWDER & HONEY CONSUME it in MORNING, for few months…………………………

5. PATIENT COUNSELLING TIPS (DO’S FOR FIBROIDS) :1. EXERCISE REGULARLY2. DRINK PLENTY OF WATER A DAY3. CONSUME WHOLE GRAINS, LIKE OATS, BROWN RICE, ETC4. EAT BEANS, NUTS, SEEDS5. EAT PLENTY OF GREEN VEGETABLES6. EAT PLENTY OF FIBER RICH FOODS7. COMBAT OBESITY, BY PROPER MEDITATION & FOCUSSING ON

JUSTIFIABLE FOOD CHOICES………………………………….

6. PATIENT COUNSELLING TIPS(DON’T’S FOR FIBROIDS):1. AVOID JUNK FOODS2. AVOID FRIED FOODS AS MUCH AS POSSIBLE3. AVOID RED MEAT & HAM4. AVOID STRESS AS FAR AS POSSIBLE5. AVOID ALCOHOL CONSUMPTION6. AVOID HIGHLY SUGARY PRODUCTS………………………………..

BIBLIOGRAPHY/ REFERENCE :1. www.sciencedaily.com/releases/2009/12/091204.html2. www.top10homeremedies.com/home-remedies-fibroids.html/33. www.mayoclinic.org4. www.healthline.com5. Thomason.P; Lin.C.Eugene; “UTERINE LEIOMYOMA(FIBROID)

IMAGING”; emedicine.medscape.com………………………

THANK YOU !!!!!

@RXVICHU-ALWZ4UH!